Healthcare quality encompasses the structures of care, care-delivery processes, and patient outcomes. The Centers for Medicare & Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC), and National Quality Forum (NQF) have each announced that quality measures should focus only on care outcomes. The easiest aspect of care to measure, care outcomes answer such questions as:

• Did the patient improve?
• Did treatments restore function?
• Is pain relieved or manageable?

The focus on outcomes leads some to believe care structures and processes aren’t important. But nurses know that’s not the case. For instance, having an adequate number of baccalaureate-prepared nurses with good support and administrative staff is integral to a structure that improves the chance of delivering excellent patient care. The processes of care—including addressing patients by name, ensuring documentation of accurate information, and working with patients to develop plans of care consistent with their needs and preferences—enhance patients’ successful engagement in their care.

The structures and processes of care also improve outcomes. Because much of what nurses do is process oriented, we can work to ensure patients understand the processes while making certain that the work we do to manage quality in these processes is transparent to the nurses responsible for doing the work.

Improving the processes of care promotes better quality. The manufacturing industries focus on improving quality processes to ensure better outcomes. Kanban cards, used in lean production methods, are an example; these cards allow workers to stop processes when products don’t meet quality requirements.

When the quality of care isn’t adequate, nurses are in a unique position to stop processes, too. Suppose, for example, a nurse caring for a low-income patient in a rural hospital reviews his discharge instructions and discovers the physician prescribed dabigatran, a new-generation and costly anticoagulant medication, to treat atrial fibrillation. Instead of simply giving the prescription to the patient, knowing he can’t afford to fill it each month, the nurse could speak to the physician about the relative value of this prescription compared to a less costly drug, such as warfarin. The outcome of this conversation could be that the physician prescribes the cheaper drug, increasing the likelihood that the patient will adhere to the medication regimen and decrease his risk of stroke. Such discussions could lead to cost savings, lower morbidity and mortality, and greater patient satisfaction.

Nurses are at the forefront of improving healthcare quality. ANA’s National Database of Nursing Quality Indicators^® (NDNQI^®) has been meas¬uring quality at all three levels—structure, process, and outcomes—since 1996. Over the last several years, NDNQI has grown to include nearly 2,000 participants, each seeking to improve nursing care at the unit level. To improve nurses’ ability to capture the most accurate information, ANA is developing electronic quality measures (e-measures) that will capture quality-related data directly from the electronic health record (EHR). The first measure will address pressure ulcers. Once it has been tested and validated, more mea¬sures will follow using the same framework. Currently, no e-measures have been built exclusively for EHR capture, so ANA might produce the first one. Pilot testing is underway through ANA’s partnership with the University of Kansas School of Nursing.

Another exciting opportunity is emerging from the American Nurses Credentialing Center, which is expanding its Magnet Recognition Program^® into the ambulatory care setting. As health care changes and more payment models move to patients’ homes, medical clinics, and other non-acute settings, more nurses will be moving as well. To adapt, ANA is adjusting its measurement of quality to include ambulatory care by developing quality and performance measures specific to ambulatory settings. To support this work, ANA has convened the Ambulatory Measurement Summit, which includes representatives from payers, measure developers, providers and, most importantly, nurses. This discussion will take some time to sort out, but the result will be a better understanding of what high quality looks like outside the acute setting and how to measure it effectively.

Darryl W. Roberts
Senior Policy Fellow at ANA